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WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 ORIGINAL <br /> R` ������ <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Vpllcation is hereby made to San Joaquin county for a permit to construct and/or install the work described. This application is made In compliance with San <br /> Joaquin County Development Title,Chapter 9.11(1`5.3 and the Standards of San Joaquin County Public Health Services,Environmental He <br /> NELL Location\\O�� Health <br /> Division. <br /> W , D urea ,Tarr 14"Cross Street City Tf 4L�7 Zip $3 7 b Parcel# ! 5 S - I,3 J. D y <br /> T 0 <br /> G;of.�e • r-.a., �ucl e.,...P.al City ZipgS2-)6Phone# 035 - 33"1q <br /> PROPERTY Owner `C'e�o.n�S�� Address ,bW ii cr=4 <br /> rLi\t om^ 9X41 �Logo1l 'o <br /> �b `�\� ci Z p uo# Phone,#`�\b 11 1 y ) o <br /> C-67 Contractor qa W 1t1k\\,f\N Address ty <br /> Address- <br /> cS <br /> Consul t I Sub ConVactor Gx.o\?� <br /> �cs-� �t'` t�y 1 � Sfi. cuyjlVo(,41i0uc# — Phone#2 U9 S zZ I19 <br /> GIS Coordinates:X <br /> y.,TownshipRange Section <br /> WORK TO BE PERFORMED: DESTRUCTIONS(choose type below) <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') O OVER-BORE <br /> O SOIL BORING# O PRESSURE GROUT <br /> pWELL# ttv+J O\ �L � Isy 'Lot <br /> "Other: SALQ o aLh4 -t- \y\°'- Wd`Y-Q\ow+ Gmut Speclficatlons: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 11MONITORING AHOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?DYES ONO WELL CASING DIA:_ <br /> D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: O STEEL D PVC D OTHER: <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED:, D AUGERS D HOSE <br /> O AIR SPARGE D PUSH POINT GROUT SEAL PUMPED: Dyes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> O SOIL BORING D HAND AUGER GROUT SPECIFICATIONS: BOLTED TRAFFIC BOX or O STOVE PIPE <br /> D 07HER: O OTHER APPROX.BORING DEPTH 0 <br /> c _ _ ` - 1� CONDUCTOR CASING PROPOSED? (If YES,list specificatlons here): <br /> -COMMENTS: �- x 0.N. )C o�UvvLpy. S `1`\`x'2- w0 r1 C..qkQ - <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ord-'nees le&MCF egulations,and all applicable California State Laws. <br /> \\\1� 5 FF(/-- IILL I)Ml� <br /> Signed zt Tkle/Company I <br /> Print Name tom` r�`� d� �A ^`�w Date <br /> DEPARTMENT rUSE ONLY T <br /> Lo <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> ��00 17�r Kao 2CJ �w <br /> WORK PLAN DATED: A.,�ost t4 ZC9DZ <br /> /Ja4 Date Issue <br /> G (>G�27/Uj Area �`r�`3 <br /> Application Accepted By /",u l e'�"�`� d r Date <br /> Grout Inspection By <br /> Date Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID#, <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3501 MLj g9 °`' Ili 15 CrvTiZ 0� 61 63 00343 <br /> C-57--V— WCy/-WAIVER_ C-57 etter ofAuthorization to sign permits Encroachment dock 9/27/00 <br /> GIZ& Tr fI !p ICr 2 P2(uu�f <br /> 60 39dd NOO-U HIAId EEbE99b90Z 99:EI I00Z/BZ/Z0 <br />